Lithium is prescribed to treat and prevent episodes of mania. Mania is a frenzied, abnormally excited mood state that impacts people with bipolar disorder. Bipolar disorder formerly called manic-depressive disorder is a disease that may cause episodes of depression, episodes of mania, and other abnormal mood states. When in a manic episode people often behave in ways that are very destructive and hurtful to themselves and those they love.

I’ve tried many other medications besides Lithium, but I always come back to the realization that for me Lithium works best and at a very low dose. I’m thankful that I’ve found a tool to help me manage my mood swings. People respond to medications very differently. What works for me may not work for you.You may have to try a few medications and change them around at different times depending on how your life is going – but hang in there - you will find a solution and you will get stable.

There are a variety of things that I do to help my mood perk along during the different seasons. The summer’s sun provides warmth and produces vitamin D. That’s supposed to be good for you. Whether it really is doesn’t matter – the sun feels marvelous and is a natural mood lifter. I spend as much time as possible boating in the San Juan and Canadian Gulf Islands. Being on the water creates a calm and balance in me that is unequalled on land.

As spring approaches, I get excited about digging in the yard and planting vegetables and flowers. When the budget allows, I hire a gardener to do the mowing and weeding so that I can enjoy the fun parts of dirt digging. Fall is a great time to relax and spend time outdoors observing nature. The birds are busy all year round, but in the fall they scurry about hunting for food and seem eager to feed from the feeders placed close to the house. In winter, I tend to hibernate and become dreary and depressed unless I find an activity to keep me focused and engaged. My winter mood lifters involve staying active with shopping, going to lunch with friends, and working on a hobby or two. I also find that mild exercise helps me weather the cold, dreary, gray days of winter.

So, enjoy the sun, shop and share time and food with friends, dig in the dirt, find a winter hobby, and stay in rhythm with yourself and the seasons.

The authors state: “Participants found that their wellness depended on a number of things that were within their control. However the data indicated that there was not a simple ‘one fix fixes all’ approach. In the “Stay Well” study, most participants:

• recognized the importance of taking their illness seriously
• demonstrated that staying well was within their control
• made changes in their lives to stay well
• learned to get on with their lives while remaining mindful of their illness.”

To be included in the study, people diagnosed with bipolar disorder must have remained episode free for the past 2 years. The only concern I have with the participant’s being episode free and exhibiting wellness is the possibility that the people in the study may have very mild cases of bipolar disorder and that the techniques they use to stay well may not be effective for people with severe bipolar disorder. I’d like to know more about the participants’ previous episodes and the designation and severity their bipolar disorder.

The definition of the concept of “staying well” included the following: the  acceptance of diagnosis, mindfulness, education, identify triggers, recognize warning signals, manage sleep and stress, make lifestyle changes, treatment, access support, and stay well plans.

According to the article, 100 people were included in the study. There were 63 women and 37 men. Ages ranged from 18 to 83 years, with 86% over the age of 30. Duration of time since last episode of illness ranged from 2 years to > 50 years. In the sample, 76% of participants were in paid employment. In addition, 36% of participants were parents.

The results showed that “Participants actively managed bipolar disorder by developing a range of strategies to stay well. These strategies were based on participants’ individual needs and social contexts. The strategies included acceptance of the diagnosis, education about bipolar disorder, identifying both triggers and warning signals, adequate amounts of sleep, managing stress, medication and support networks.”

One of the keys to staying well was the ability to be mindful of their illness. By being mindful, participants were more fully able to develop individual stay-well plans, including intervention strategies to prevent episodes of  the illness. The full article shares specifics and it is well worth reading. http://researchmatters.net/publications/StayWell.pdf

The one thing that they were not was able to do was pinpoint that I had bipolar disorder and direct me to a psychiatrist for help. In fact all of them were adamant that I was a “normal neurotic”. I’m not sure exactly what that means but if felt good to be reassured that I was within the normal spectrum.

During my most recent manic episode my therapist assured me that everything that I was doing was good for me including leaving my husband of 30 years, running away from home, etc. Even after the manic episode was under control my therapist refused to admit that I was bipolar or that I’d had a manic episode. She said that I was so self confident and self-assured and she was convinced in her mind that my actions were perfectly rational and in my best interests. Then she watched me crash and saw the other side of the illness. I stopped seeing her soon after that because I was not confident in her ability to help me pinpoint when an episode was starting up.

I learned a very important lesson from all this. If you do decide to participate in therapy whether it is cognitive, cognitive-behavioral, interpersonal & social rhythm therapy, just be sure that the therapist you select has a lot of experience working with clients who have bipolar disorder. Your psychiatrist may be able to recommend therapists with expertise in mood disorders.

I’m not sure any therapist could have kept me from making the mistakes that I made during my last manic episode, but I truly believe that a therapist with experience dealing with bipolar clients could have helped me minimize the damage that I did to myself, my family, and my bank account.

During a manic episode you usually have tons of energy, are sometimes irritable, and often overly self confident. During a manic phase you may schedule more tasks than you can accomplish. Risky behavior is also a symptom of mania. You might spend too much money or experience an overly active sex drive – this is called hypersexuality. Your judgement recedes and you might make choices and engage in behaviors that put you at risk.

During a depressive episode you can feel very isolated and tired. You might feel slowed down, sad, and have changes in your sleep and eating habits.You may also have difficulty with memory and concentration.

Some people who suffer from bipolar disorder will also have psychotic symptoms such as hallucinations and delusions. If a person is hallucinating with bipolar disorder they will see or hear things that are not there. Grandiosity is common. Usually these symptoms happen during a severe manic episode but not always.

Approximately 6 million Americans have bipolar disorder. You could have bipolar disorder and not even realize it. For me, a diagnosis of bipolar disorder explained so many things in my life. If you suspect that you have bipolar disorder contact your doctor and ask for a referral to a good psychiatrist (pdoc). Pdocs are highly trained physicians well qualified to diagnose and treat bipolar disorder.

My friend just quit his job and is spending all his money. He stopped taking his medication. He has a plan to start a new international business but he doesn’t know the first thing about it. He isn’t worried about anything though. I’m sure that he is having a manic episode. Does a manic person believe that they are making good decisions and functioning well when they are manic? My friend is destroying his life and no one can talk him out of it.  Is there anything that I can do or say to get through to him?

Your friend probably won’t be able to listen to you while he is manic. He’s feeling really good right now and doesn’t want those feelings to stop. He’s most likely convinced that he’s on the right path, is perfectly well, and is behaving and thinking correctly .

Feeling pretty cool and together is one of hallmark features of early mania for many people. In a manic state you feel so sharp and acute. You’re sure that you know everything and you are convinced that you can do anything. You have creative and grandiose ideas like starting a new business and/or maybe saving the world. Mania, especially euphoric mania is very addictive. It’s hard to give up once your enmeshed in it. Don’t bother arguing with your friend. I guarantee that he’ll have 10 counter agruments for every point you make.

Until he’s ready to help himself  there’s not much you can do.  Some people have to hit bottom pretty hard before they take their Bipolar Disorder seriously. It sounds like he will continue on his manic journey until it winds down on its own, or until he gets the help that he needs to stop the episode.  Good luck to you and your friend.

Begin by identifying the stressor(s) that are causing you to feel unstable. Once you have identifed the stressor(s) you will want to start thinking about a strategy for resolving them. For example, imagine that you’ve been through a manic episode and you’ve charged tons of money on your credit card. You can’t pay your bill on time and you are worried about mounting debt and you also feel very ashamed about your behavior. First of all, feeling ashamed about behavior that occured when your frontal lobes were offline is not useful. Give that up. It won’t help you or anyone else.

Now, you are ready to prioritize the issues creating the stress and define the action steps needed to alleviate them. I find making lists to be very helpful. If you are unable to identify the stressor or prioritize the issues and define action steps to resolve the problem, then you may have some kind of barrier that is keeping you from doing so. Gather more information about the stressor and problem that has resulted from it. Continue to gather information until you understand it thoroughly. It’s quite all right to ask friends and family for help in removing barriers and clarifying issues so that you are able to know what steps you need to take to fix the problem and reduce the stress.

Create an action plan. In this example you might call the credit card company and ask them to work with you on a payment plan that will minimize interest payments and help you pay off your card over time. Another action you might take it to make sure that your credit limit is lowered to an amount that will not create a debt problem for you if you happen to max out your card again.

The steps in this stress reduction plan include: identifying the problem, deciding on a strategy for solving the problem, listing all the steps needed to implement your strategic solution, taking the steps you’ve outlined, and then evaluating how well your solution worked.

Another key to being able to do this is to drop all guilt for your behavior and take steps to move your life forward in positive ways while reducing stress. Doing these things can help ensure that you don’t end up repeating behaviors that wreak havoc in your life.

Here is the link to the video on live leak

I find it interesting in retrospect that I earned my Ph.D. in cognition, learning, and memory. I certainly didn’t decide to study those subjects because I had Bipolar Disorder and thought that someday I might have trouble remembering things. I can’t help but feel however, that it seems more than coincidental that I spent so much time - 6 years in fact - studying cognitive processing and how humans learn and recall information. I also studied metacognition. Metacognition is the executive in our brain making decisions and running the show behind the scenes. During a manic episode, metacognitive processes stop working, and a manic person often makes bad decisions about finances, family, and/or relationships, and engages in risky activities because they do not perceive the risk.

On many of the Bipolar forums, I’ve noticed that quite a few people seem to have trouble remembering, reading, or concentrating. These symptoms come and go, but for me the memory issue is fairly consistent! I remember my childhood but only the bad times. Those events stand out, but the normal everyday memories are very dull and I have to spend a lot of time trying to dredge them up to make them bright and clear. So much for long term memory. My mom is the same. She is 86 and sharp as a tack but a bit hazy on the past. I suppose that’s normal for someone her age.

On the short term memory side of things – I just don’t know. Some days are fine and on other days I’ll struggle to find the word that I’m looking for (tip of the tongue syndrome). Have you ever gone into another room to get something, find yourself in the room, and then wonder what the heck you went in that room to get? There is a good side to some of this. I can read a book and then six months later pick it up and enjoy it all over again. Saves quite a bit of money on books.

You might want to react right now and say “It’s obvious, it’s the medication causing your memory loss”, but that’s too easy. I’ve always been this way both before and after starting mood stabilizing medications.

At one point, I was so concerned that I took myself to a neurologist and had him run an MRI of my brain and it turns out that I have a lovely brain. It is lush with lots of volume and very healthy looking. The neurologist showed me my brain in 3D using very fancy software. High tech. I was reassured and told that my brain is fine and that I do not have signs of memory-loss related diseases. That’s when I began to wonder if it could be a part of Bipolar Disorder.

Does Bipolar Disorder impact your memory? If so, how and when?

Some of the early warning signs of depression include finding yourself feeling extremely tired in the afternoons even if you’ve had a good night of sleep. You may start to become reclusive and find people bothersome and annoying. I usually have no energy to do simple tasks like make dinner or do anything that takes any amount of energy. I can sleep for 10-12 hours and still not want to get up in the morning. I always crave carbohydrates and chocolate, so I’m not convinced that either of those are a sign of bipolar depression, but some clinicians believe them to be among the early warning signs, so I’m adding them to the list. Finding that you have lost interest in activities that you previously enjoyed, or feeling as though you can not concentrate are also early warning signs. Having thoughts about suicide is a warning sign that you must not ignore.

For hypomania, you may find yourself energized and excited about things that you found pretty dull and boring only a few weeks ago. You might notice that you are spending many more hours then usual doing work or receational activities. You may throw yourself into your work, read tons of books, or do most anything in a fairly intense and compulsive way. I find that I become very productive when hypomanic, but as I progress into an episode, I become dysfunctional and anxious. But that’s another article. In this article, we are focused on early warning signs.

Let’s move on to mania. For me, the early warning signs are the same as for hypomania, but more intense. I am pleasure seeking and overly self confident. I have lots of energy and I’m often very talkative and “charming”. Or at least I think I’m charming. When heading towards a manic episode, I become easily distracted and can become irritable and impatient with other people who seem very dull and as though they are moving in slow motion. Also, I am unable to sit still and I find myself continually moving around. It becomes impossible for me to relax. I am impulsive and my decision making processes go out the window.

You’ll want to do all you can to monitor and detect the early signs of an oncoming episode. It’s no fun having an illness take over your life, your behaviors, and your thinking, while you tag along for a potentially dangerous and destructive ride.

Key Recovery Concepts from the Depression and Bipolar Support Alliance (DBSA)

• Hope. With good symptom management, it is possible to experience long periods of wellness. Believing that you can cope with your mood disorder is both accurate and essential to recovery.
• Perspective. Depression and manic-depression often follow cyclical patterns. Although you may go through some painful times and it may be difficult to believe things will get better, it is important not to give up hope.
• Personal Responsibility. It’s up to you to take action to keep your moods stabilized. This includes asking for help from others when you need it, taking your medication as prescribed and keeping appointments with your health care providers.
• Self Advocacy. Become an effective advocate for yourself so you can get the services and treatment you need, and make the life you want for yourself.
• Education. Learn all you can about your illness. This allows you to make informed decisions about all aspects of your life and treatment.
• Support. Working toward wellness is up to you. However, support from others is essential to maintaining your stability and enhancing the quality of your life.

There is lots more excellent information at the Depression and Bipolar Support Alliance site. Check it out.

Content Source: Depression and Bipolar Support Alliance

I’ve been reading about diet and modifying mine based on suggestions from my psychiatrist (pdoc), general physician, and a renowned heart surgeon who goes into great depth in his book, Dr. Grundy’s Diet Evolution about how many of the foods we consider good for us turn into sugar too quickly when they enter our system. My pdoc says that he recommends a diet with a focus on healthy proteins and vegetables. In the Bipolar Handbook by West Burgess, M.D., Ph.D.  says that “It is his impression that a diet high in protein and low in starch will not worsen Bipolar Disorder and may help it”.  I’m seeing a convergence of opinion on what constitutes a healthy diet with the main difference being disagreement about the amount of grains to include in the diet.

Did you know that the supposedly healthy oatmeal that you eat to lower your cholesterol turns into sugar immediately when you consume it? It turns into a huge sugar blast. I was shocked. Many of the fruits that we love also are packed with sugars that tell our bodies to according to Steven Gundry, M.D., F.A.C.S, F.A.C.C. to “store fat for the winter.” With many of us trying to do all we can to stay stable and maintain a healthy weight, we don’t need our genes fighting us every inch of the way.

My diet experiment is just beginning. I’ve been eating a moderately high protein diet and including all the salad and green vegetables I can consume. It may be a placebo effect but I feel good (no not manic).  

I’ll keep you posted. If you’ve found foods that either help or hurt your illness, please share.

Dr. Grundy’s Diet Evolution, 2008, Steven R. Gundry, M.D., F.A.C.S., F.A.C.C., Three Rivers Press, Crown Publishing.

The Bipolar Handbook, 2006, Wes Burgess, M.D., Ph.D., Avery – Penguin Group (USA) Inc.

After the initial trigger(s) activate the genes and the illness, it then presents as major mood swings that come and go over varying periods of time. These are called episodes. Every individual has their own unique triggers that can activate  an episode. Although everyone is different and there are a variety of manifestations of the illness, many of the triggers are common and shared. For example, lack of sleep is often a trigger for a manic episode.

Again, even though the illness has a strong genetic component thought of as the underlying cause of the disease it may take a triggering event for the Bipolar Disorder to actually manifest itself. Trauma can trigger the disorder as well as travelling to a different time zone. Other common triggers include stress, hormones, and even taking street drugs. I’ve found that mood stabilizing medications are the key to keeping the episodes from recurring so quickly, and key to keeping them less intense and shorter in duration.

In an article on their site, the Mayo Clinic staff writes: “Several factors seem to be involved in causing and triggering bipolar episodes:

• Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
• Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
• Hormones. Imbalanced hormones may be involved in causing or triggering bipolar disorder.
• Inherited traits. Bipolar disorder is more common in people who have a blood relative (such as a sibling or parent) with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.
• Environment. Stress, abuse, significant loss or other traumatic experiences may play a role in bipolar disorder.”

The causes of bipolar disorder probably vary between individuals. Twin studies have been limited by relatively small sample sizes but have indicated a large genetic component. If a member in your direct family has bipolar disorder you will be much more likely to have the illness as opposed to members of the general population. Genes that contribute to the disease are being identified. There is more than one gene thought to be involved in the illness making it a complex disorder to unravel.

Environmental factors may play a large role in triggering the illness. Some people believe that the environment, and other variables interact with a person’s genetic disposition thereby triggering the disease. It is not a simple task to sort out the cause of this disorder. It involves a complex set of variables. However, the closer we get to figuring it out, the closer we will be to finding a cure.

Bipolar Disorder makes it difficult to regulate your emotions. “Normal” people tend to react “normally” (within a range of behaviors considered normal) to events in predictable ways. People with bipolar disorder often overreact to events that are triggers for them. For example, imagine going to a show that you really loved and coming out of the theatre elated and happy. Those are normal, appropriate, emotions related to an event that you just experienced. Now take the theatre event away, but imagine experiencing those same feelings (magnified 100 times), and that is euphoric mania. There is no rhyme or reason for the feelings. The overblown emotions are caused by the illness. Euphoric mania is wonderful at the beginning but it can turn dark and scary as it progresses towards one of the inevitable outcomes – the crash.

It was well know even in ancient times, that mania can manifest in several ways or change during an episode. During Hippocrates time, scholars observed, described, and recorded different mental states including mania.  Aretaeus of Cappadocia, a  famous Greek physician, lived in Alexandria in the first century AD and wrote the following: “Some patients with mania are cheerful – they laugh, play, dance day and night, and stroll through the market, sometimes with a garland on their head, as if they had won a game: these patients do not worry their relatives. But others fly into a rage…”  In my experience, I am happy and confident, kind and loving to those who support my mania and allow me to revel in my euphoria. I’m the opposite with anyone who tries to thwart me or tell me that I am not myself, and heaven help them if they try to tell me that I need help.  

There is a wide range of emotions and behaviors that typify any kind of mania and they include at least one but usually several of the following:

• euphoric mood (excessively happy but may become angry or irritable)
• high self-esteem
• increased psychomotor activity
• optimism
• exuberant energy
• increased goal-directed activity
• diminished need to sleep
• distractibility
• talkativeness
• racing thoughts
• grandiosity
• disinhibition
• impaired insight
• financial extravagance
• increased risk-taking
• high libido
• sexual promiscuity

Here is how Julia A. Fast an author about Bipolar Disorder describes specific symptoms associated with Euphoric Mania.

“An extreme desire for:

• sex with no thoughts of the consequences
• spending with no thought of the cost
• travel – no matter who you leave behind
• creative projects where you stay up all night with an ‘amazing idea!’
• quick results-  the manic person finds ‘slow’ people very annoying
• talking with strangers

People with bi-polar euphoric mania also experience:

• less need for sleep with no tiredness the next day
• excessive ideas that just feel so wonderful they have to tell everyone about them!
• a general sense of well being that is hard to describe unless you have experienced it!
• inability to let others talk.”

A friend asked me about treatments for the manic phase of Bipolar Disorder? I found myself stumbling to answer because there are a variety of medications out there but not all of them work well for everyone. What works for one person may not work for another, and that’s why taking time to work with your doctor to find the right medication or combination of medications is critical. I’ve found a nice combination that is working well for me at the moment, but it has taken me more than five years and lots of trail and error to get to this point. The frustrating thing is that medications can work well for a while and then stop working. When they are working they help function and enjoy life more fully. When they fail to work, it just means that you need to go in and make adjustments to your medications with your doctor, and keep adjusting until you get back on track.

In some of the most recent studies, researchers have found that Lithium is highly effective for preventing relapses in mania. Combining Lithium with Depakote is also effective for many people. If someone is in an acute phase of mania, a combination of one of both of these mood stabilizers along with an antipsychotic can be effective in reducing symptoms quickly.

If you are experiencing a manic episode whether you feel euphoric and happy, or pressured, irritable, and short tempered, please contact your psychiatrist right away and get help. Manic episodes may feel good at the beginning but they usually end badly, and can destroy your finances, your health, and your relationships.

References:

Bipolar Disorders, Mixed States, Rapid Cycling and Atypical Forms, 2005, Edited by: Andreas Marnero, Frederick Goodwin,Cambridge University Press.

Julie A. Fast’s Bipolar Happens Blog

Of2Minds: The Creative Bipolar Life from Center for Documentary Studies on Vimeo.

• No way – 12%
• Maybe, not sure - 16%
• Yes – 72%

72% of respondents said ”Yes”. 16% said “Maybe”, and 12% responded “No.”  18 people cast a vote. Granted, this is not a scientific poll, but it does give you a higher social anxiety rate than many of the rates reported in the research literature. People also commented about what specifically made them feel most anxious. The overwhelming majority of people wrote about the need to avoid large crowds, parties, and stores, giving talks, and they also indicated being very uncomfortable when interacting with people they did not know well. Most of the respondents said that they do not feel social anxiety when they are hypomanic or manic, and their social anxiety is most prevalent when they are depressed.

For me, one of the most difficult parts of coping with bipolar disorder is dealing with the bouts of anxiety that seem to leap up out of nowhere and knock me off my feet. So, I thought I’d check out the research and other resources to see what experts say about the relationship of anxiety to bipolar disorder.You will see the term comorbidity used quite a bit in the research literature, and that essentially means that there are two separate diseases or disorders existing simultaneously with and usually independently of each other. Research also indicates that anxiety may be an actual component of bipolar disorder and not a separate disorder from bipolar disorder.

Dr. Jim Phelps describes these two different types of anxiety very well. The first is not a separate disorder but is an integral part of  bipolar disorder. With this type of anxiety, the person feels agitated, can’t seem to stay still, and feels uncomfortable in their own skin. To me this sounds like a part of mania or a mixed state rather than the low level kind of anxiety that I often feel. Dr. Phelps description fits me when I’m in a mixed state. He also describes the different types of anxiety disorders that sometimes exist along with bipolar disorder, and they include generalized anxiety disorder (GAD), social phobia, panic disorder, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and specific phobias. (1) I find that I especially want to be reclusive and avoid large social groups when I’m in a depressed mood.

According to well respected researchers in Brazil: ”Epidemiological and clinical studies have reported a high prevalence of anxiety symptoms in bipolar disorder, either in manic or depressive episodes, although these symptoms do not always meet criteria for a specific anxiety disorder. In addition to anxiety symptoms, bipolar disorder frequently presents with co-morbid anxiety disorders.” These researchers agree with Dr. Phelps. There is anxiety that is a part of bipolar disorder illness, and there are separate anxiety disorders that a person can have along with bipolar disorder. Most of the research studies that I’ve read deal with the cormorbidity of anxiety disorders with bipolar disorder rather than studying instances where anxiety is an integral part of the bipolar illness. (2) How you might tease out those two distinct types of anxiety in a study could be tricky.

According to Freeman, et al., “Symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder…. A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder.” (3)

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study was a huge research study that lasted five years and included over 4,000 participants. The study provided an enormous amount of data that will be studied and disseminated for quite some time.  STEP-BD was funded by the National Institute of Mental Health (NIMH). Researchers discovered that there are many people with bipolar disorder who also cope with anxiety.  More than 50% of the study participants also had an anxiety disorder in addition to bipolar disorder. (4) 50% is significant and that may not include those whose anxiety is an integral part of their bipolar illness and not a separate anxiety disorder.

A Turkish study investigated the prevalence of anxiety disorders in bipolar participants whose illness was in remission, and their influence on the illness severity. The authors state: “Bipolar subjects with anxiety disorders were younger, had earlier age at onset of illness, and were over represented by female participants. Those with earlier onset illness were compared to those without anxiety disorders. The study demonstrated that (1) anxiety disorders were highly prevalent in the bipolar study participants , (2) individual anxiety disorders, particularly social phobia and panic disorder impacted illness severity, (3) bipolar participants with comorbid anxiety disorders tend to have a poorer outcomes and are less responsive to treatment, and (4) anxiety tends to be associated with an earlier age at onset of bipolar disorder and results in a more complicated and severe disease course.” (5)

Another interesting study examined the comorbidity of anxiety disorders among patients with bipolar 1 disorder who were currently in remission.  This  study assessed the occurance of lifetime and current prevalences of anxiety disorders among 70 patients with bipolar 1 disorder. Researchers used structured diagnostic interviews to gather data regarding the association between anxiety disorders and bipolar disorder including demographic and clinical variables. The researchers found that forty-three or 64.1% of bipolar 1 participants met the DSM-IV criteria for at least one anxiety disorder. Obsessive-compulsive disorder at 39% was the most common coexisting lifetime anxiety disorder, followed by simple phobia at 26% and social phobia at 20%. The authors state that: “The presence of anxiety disorders was related to significantly higher scores on both anxiety and general psychopathology scales. The results of the present study support previous findings of a high rate of anxiety disorders in bipolar 1 disorder cases and indicate that the presence of an anxiety disorder leads to more severe psychopathology levels in bipolar 1 patients.” (6)

In yet another study conducted by a group of scientists from the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies, researchers reported that participants with bipolar 1 disorder and bipolar 2 disorder had similar demographic characteristics and ages of onset of their first episode. The bipolar 2 disorder group had significantly higher lifetime prevalence of anxiety disorders in general, and had more social and simple phobia disorders in particular compared to those with bipolar 1 disorder. (7)

In summary, there appears to be compelling evidence that there are two distinct types of anxiety that can impact bipolar disorder illness: one that is an integral component of the bipolar illness itself, and another that includes separate, measurable, and disgnosable anxiety disorders that exist independently from the bipolar illness itself. I’m not sure how clean cut the lines of demarcation are between these two types of anxiety patterns, or what the treatment implications might be. If anyone has any information to contribute please do.

1. Dr. Jim Phelps, http://www.psycheducation.org

2. CNS Drugs. 2009 Nov 1;23(11):953-64. doi: 10.2165/11310850-000000000-00000. Epidemiology and management of anxiety in patients with bipolar disorder. Kauer-Sant’Anna M, Kapczinski F, Vieta E. Bipolar Disorders Program and Molecular Psychiatry Unit, INCT-TranslationalMedicine, Hospital de Clinicas(HCPA), Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

3. Affect Disord.  2002 Feb;68(1):1-23.  The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and
treatment issues. Freeman MP, Freeman SA, McElroy SL. University of Cincinnati College of Medicine, Biological Psychiatry Program, Department of Psychiatry.

4. American Journal of Psychiatry, 161, 2222-2229.Simon, N.M., Otto, M.W., Wisniewski, S.R., Fossey, M., Sagduyu, K., Frank, E., Sachs, G.S., Nierenberg, A.A., Thase, M.E., & Pollack, M.H. (2004, December). Anxiety disorder comorbidity in bipolar disorder patients: Data from the first 500 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD).

5. Anxiety Disord. 2011 Feb 21. [Epub ahead of print] The comorbidity of anxiety disorders in bipolar I and bipolar II patients among Turkish population. Ibiloglu AO, Caykoylu A. MersinTarsus State Hospital, Department of Psychiatry, Mersin, 33400, Turkey.

6, Psychopathology.  2002 Jul-Aug;35(4):203-9.  Comorbidity of anxiety disorder among patients with bipolar I disorder in remission. Tamam L, Ozpoyraz N.

7. Affect Disord. 2003 Jan;73(1-2):19-32. The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? Judd LL, Akiskal HS, Schettler PJ, Coryell W, Maser J, Rice JA, Solomon DA, Keller MB. National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies, USA.

Lifestyle behaviors, including sleep, diet, and exercise choices can significantly impact your moods. There are many things you can do to get your symptoms under control and keep depression and mania from dominating your life.  Managing Bipolar Disorder requires exploring your current habits and adapting them to maintain optimal mood stability. It’s not always easy to change behaviors but with practice and self encouragement it can be done. Self monitoring your progress and rewarding yourself when you make positive changes is a great way to motivate yourself.

Sleep

Events that result in loss of sleep may spur manic behavior in people with bipolar disorder, according to results of studies presented at the 1997 Second International Conference on Bipolar Disorder in Pittsburgh. The likelihood that a manic episode will occur can be reduced by following very regular daily routines.

Too much sleep can also worsen your mood. Try to go to bed and wake up at around the same time every day. However tempting it may be, try not to break this routine on weekends when you may want to stay up much later or sleep in. Your overall sleep will be better if you stick to your routine seven days per week. I have a terrible time with sleep. When manic I don’t want to sleep and don’t, and when I’m depressed I have great difficulty waking up in the morning and can sleep around the clock.

Having a Structured Routine

Setting and sticking to a daily schedule can help stabilize Bipolar Disorder. Set times for sleeping, eating, socializing, exercising, working, and relaxing, and try to maintain your schedule, even through emotional ups and downs.

Jay Carter, Psy. D. says that “People who are bipolar think outside the box, but they need a box to think out of.” That’s brilliant and very true. In his book, Dr. Carter talks about the importance of having a routine during the times when your prefrontal lobes go out. If you have a routine, at least you know what to do next. If you go to the gym everyday at 3pm, then you know what you are supposed to do. Without a routine, it can be very disorienting to all of a sudden find yourself lacking your prefrontal lobe function. I can attest to that.

Diet

Eating a healthy diet low in refined flour, sugar, and fat is probably good advice for everyone. There seems to be a link between food and mood. Eat lots of fresh fruits, vegetables, and whole grains and limit your fat and sugar intake. Space your meals out through the day, so your blood sugar never goes too low. I hate to say this but I keep reading it so – avoid chocolate, caffeine, and processed foods. This is definitely an area where I have a lot of work to do. I love chocolate, caffeine, and cookies. I’ve found Fish Oil capsules to be especially helpful at least for lowering triglycerides. Some people claim that it also helps with depression. My psychiatrist encourages me to stick to protein as he believes that one component of Bipolar Disorder includes a protein deficiency. I’d rather eat chocolate!

Exercise

Research indicates that exercise has a beneficial impact on mood and may reduce the number of bipolar episodes that a person experiences. Aerobic exercise appears to be especially effective at treating or minimizing depression. Try to incorporate at least thirty minutes of activity five times a week into your routine. I enjoy doing light aerobic exercise, light weight lifting, and tai chi. Emphasis on the word light!

Stress

For me stress is a monster that tries to convince me that everything that I am doing is critically important and must be done perfectly. My stress is often irrational and self-imposed. Stress can mess with your sleep, your body chemistry, and your ability to cope. You can’t avoid all stress that would be silly and virtually impossible, but you can avoid situations that cause you great stress or places, people, or events that you know will trigger you. I work hard to pinpoint and then avoid triggers that get my mania going and it’s very hard because I’m addicted to the feelings that come with euphoric mania. So, it is a constant battle with myself to keep me out of dangerous mania territory.

You won’t always be able to avoid stress and finding ways to cope and minimize it are essential. Quite a few people use meditation and exercise for managing stress.

Changing habits is not easy, but I’ve concluded that for me making a few healthy behavioral changes will be beneficial long term and worth the short term hassle and discomfort. I’m just not sure about giving up chocolate though. Got to do more research on the health benefits of chocolate - I’m sure that I read somewhere that it’s good for you!

 
Overall:

• Lithium did better than Vaproate for mania.
• Lithium in combination with Valproate did better than Valproate alone. 
• Lithium did better for depression.
   
   
   
   
   
   

Sackett, D. L., Haynes, R. B., Guyatt, G. H. & Tugwell, P. (1991) Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown.

Slides leveraged from online slide deck titled:  Why we need research: a short history of evidence-based psychiatry. John Geddes
Oxford Clinical Trials Unit for Mental Illness.
 
 
 

In the article, What works for people with bipolar disorder? Tips from the experts. Journal of Affective Disorders, Dec. 2009,  the authors acknowledge that there is a large gap in the literature about strategies for managing Bipolar Disorder. Treatments are inadequate and there are few effective self-management strategies that have been studied, validated, and documented for use. In this study, the investigators monitored high functioning people with Bipolar Disorder and recorded the self-management strategies that they used to successfully manage their Bipolar Disorder.

The self-management strategies found to be effective were in the areas of: 1) Sleep, rest, exercise and diet; 2) Ongoing monitoring; 3) Enacting a plan; 4) Reflective and meditative practices; 5) Understanding Bipolar Disorder and educating others; 6) Connecting with others.  Hear the authors, “The findings constitute hopeful stories for people affected by the disorder and suggest further research to confirm and refine mechanisms of beneficial effect in Bipolar Disorder.”

In another article, Exercise and bipolar disorder: a review of neurobiological mediators, Neuromoleculcar Medicine, 2009;11(4):328-36, researchers reviewed articles published between 1966 and July of 2008. In their abstract they state, “Individualized exercise interventions are capable of alleviating the severity of affective and cognitive difficulties….”

In order to find appropriate studies to review, they cross referenced the term Bipolar Disorder with the following terms: exercise, neurobiology, brain, cognition, neuroplasticity, etc. They reviewed the literature and found evidence that structured exercise regimens do have positive health effects as well as ”robust anti-depressant effects”. They suggest that structured exercise is capable of “improving psychiatric and somatic health in Bipolar Disorder”.

In summary, these two studies focused on people with Bipolar Disorder. The results of both studies conclude that exercise and other self-management strategies can have significant beneficial effects on Bipolar Disorder.

Traversing through the maze of medications used for managing and stabilizing the debilitating mood swings of bipolar disorder can be daunting and frustrating. It can feel like you are on a never ending merry-go-round. a merry-go-round that leaves you on the edge of spinning in and out of control. When I feel that way, I know that my meds are not right and they need some adjusting

I’m on both Lithium Carbonate and Depakote ER in small doses. After getting used to the Depakote ER there are few if any side effects. For the first three months the Depakote ER really, really upset my stomach. My pdoc suggested that I take 500 mg of a supplement called Acetyl L-Carnitine and that made all the difference in my ability to tolerate the Depakote ER. Depakote depletes L-Carnitine. I have no idea how or why it helps with the side effects caused by Depakote but I’m glad that it minimizes the stomach upset. The combination of Lithium and Depakote ER have made a huge difference in how I feel and function. I am much calmer and less prone to anxiety, panic, and irritability now. My thought processes are clearer and I seem to be much more productive. I realize that not all the same medications work for everyone and it takes a trial and error adjustment period, (maybe several adjustment periods) to find a combination that works well to minimize symptoms with minimal or no side effects.

It has taken me several years to get to this point, and I’m glad I kept working at it. Stability makes life much less uncomfortable than it would be if I were unmedicated. If you are struggling with mood swings, anxiety, and that gripping pressure that seems to dwell inside you when your bipolar disorder is untreated, I urge you to consider seeking treatment or continuing to pursue your current treatment and making treatment adjustment with your doctor if you are not content with how you are feeling and doing at this time in your life.

Here’s a link to a great site all about psych medications:  http://www.crazymeds.us/

Ketamine lifts mood quickly in bipolar disorder

“An infusion of the anesthetic ketamine can lift mood within minutes in patients suffering from severe bipolar depression, according to a small study out this month in the Archives of General Psychiatry.

The 18 patients in the study had tried an average of seven different drugs for treating their bipolar illness, and were still severely depressed; 55 percent had failed electroconvulsive therapy (ECT), or shock treatment. But within 40 minutes of receiving a ketamine injection, their depressive symptoms improved; the effect persisted for at least three days.

Right now, medications available for treating either major depression or bipolar illness can take weeks, or even months, to work, notes Dr. Carlos A. Zarate Jr. of the National Institutes of Health in Bethesda, Maryland, one of the researchers on the study.

And as a person waits for their medications to kick in, he added, they will continue to have difficulty working and coping with social and family life; they may even be having thoughts of suicide. “We want to alleviate the suffering and get them back to their life,” he said.

Zarate and his colleagues had previously demonstrated that ketamine shots helped some patients with treatment-resistant unipolar depression, meaning they did not cycle through manic episodes. In the new study, they gave patients with bipolar illness ketamine or a placebo on two test days two weeks apart.

All of the patients were on lithium or valproate – two drugs commonly used for bipolar illness – but had not responded to treatment. Nearly all were unemployed, Zarate and his team note, and two-thirds were on psychiatric disability.

Compared to placebo, patients showed significant improvement in mood within 40 minutes of receiving the ketamine infusion, using a common depression rating scale. Symptom improvement peaked two days after the injection, but remained significantly greater than for placebo for three days.

Seventy-one percent of the patients responded to ketamine, meaning they had at least a 50 percent improvement in their depressive symptoms. Six percent responded to placebo.

Side effects included anxiety, “feeling woozy or loopy,” headache, and dissociative symptoms, meaning a temporary sense of disconnection from reality, although there were no serious adverse events. By developing more specifically targeted drugs, Zarate noted, it may be possible to treat patients effectively while avoiding these symptoms.

Ketamine appears to work by “resetting” the way nerve cells process glutamate, a brain chemical key for learning, memory, and other functions, according to Zarate. The problem in bipolar illness and depression, he explains, doesn’t appear to be that a person has too much or too little glutamate; instead, it’s likely that the way their neurons release and take up the chemical is out of whack.

First introduced in 1962, ketamine is used legally in both human and veterinary medicine as an anesthetic. It’s also a drug of abuse, at much higher doses than those used in Zarate’s research; while patients in the current study received about 50 milligrams during a 40-minute period, a dose too low to induce anesthesia, recreational users of ketamine, known as “Special K,” may take hundreds of milligrams per week.

In 1999, US regulators classified ketamine as a Schedule III controlled substance, meaning it has the potential for abuse but is also useful medically.

Ketamine could improve treatment of bipolar illness and depression in a variety of ways, Zarate said; for example, as a means to jump-start standard drug treatment, or as an anesthetic before ECT. “It’s opened the floodgate of many different directions of research, and all of them are quite encouraging,” said Zarate, who along with a co-author has filed for a patent on the use of ketamine in depression. Those rights would be assigned to his employer, the National Institutes of Health.

Efforts are already underway in Europe to develop guidelines for how ketamine should be used and prescribed to treat bipolar illness and depression, the researcher said.

In the US, research is continuing on the drug, he added, and some physicians are likely trying the drug in their patients with bipolar illness or depression who aren’t helped by standard treatments. But, according to Zarate, more research is needed on how to use the drug in the safest and most effective way.

SOURCE: link.reuters.com/wek23n Archives of General Psychiatry, August 2010.”

“How can I help myself if I have bipolar disorder?

It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment.

To help yourself:

• Talk to your doctor about treatment options and progress
• Keep a regular routine, such as eating meals at the same time every day and going to sleep at the same time every night
• Try to get enough sleep
• Stay on your medication
• Learn about warning signs signaling a shift into depression or mania
• Expect your symptoms to improve gradually, not immediately.”

To read the entire booklet online go to: Bipolar Disorder Booklet by NIMH

It shows the variation between normal mood swings and mood swings of people with Bipolar Disorder. Even with medication to control my mood swings, my moods still falls well outside the normal range from time to time and it takes constant work to try and stay in the normal range.

That’s pretty typical for many people with Bipolar Disorder who are doing all the prescribed things to stay “normal” and stable. I just have to take it one day at a time. Some days are better than others.

“There is no clear consensus as to how many types of bipolar disorder exist. In DSM-IV-TR and, bipolar disorder is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists three specific subtypes and one for non-specified:

Bipolar I disorder

One or more manic episodes. Subcategories specify whether there has been more than one episode, and the type of the most recent episode. A depressive or hypomanic episode is not required for diagnosis, but it frequently occurs.

Bipolar II disorder

No manic episodes, but one or more hypomanic episodes and one or more major depressive episode. However, a bipolar II diagnosis is not a guarantee that they will not eventually suffer from such an episode in the future. Hypomanic episodes do not go to the full extremes of mania (i.e., do not usually cause severe social or occupational impairment, and are without psychosis), and this can make bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing, crippling depression.

Cyclothymia

A history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. There is a low-grade cycling of mood which appears to the observer as a personality trait, and interferes with functioning.

Bipolar Disorder NOS (Not Otherwise Specified)

This is a catchall category, diagnosed when the disorder does not fall within a specific subtype. Bipolar NOS can still significantly impair and adversely affect the quality of life of the patient.

The bipolar I and II categories have specifiers that indicate the presentation and course of the disorder. For example, the “with full interepisode recovery” specifier applies if there was full remission between the two most recent episodes.

Rapid cycling

Most people who meet criteria for bipolar disorder experience a number of episodes, on average 0.4 to 0.7 per year, lasting three to six months.

Rapid cycling, however, is a course specifier that may be applied to any of the above subtypes. It is defined as having four or more episodes per year and is found in a significant fraction of individuals with bipolar disorder. The definition of rapid cycling most frequently cited in the literature (including the DSM) is that of Dunner and Fieve: at least four major depressive, manic, hypomanic or mixed episodes are required to have occurred during a 12-month period. There are references that describe very rapid (ultra-rapid) or extremely rapid (ultra-ultra or ultradian) cycling. One definition of ultra-ultra rapid cycling is defining distinct shifts in mood within a 24-to-48-hour period.

Challenges

The experiences and behaviors involved in bipolar disorder are often not understood by individuals or recognized by mental health professionals, so diagnosis may sometimes be delayed for 10 years or more. That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites……”

To read the entire article with accompanying citations go to: http://en.wikipedia.org/wiki/Bipolar_disorder

Because individuals with both depression and bipolar disorder experience a glutathione deficiency, an antioxidant that protects cells from toxins, researchers in a new study scheduled for publication in the September 15th issue of Biological Psychiatry sought to evaluate whether N-acetyl cysteine (NAC), an over-the-counter supplement that increases brain glutathione, might help alleviate depressive symptoms.

Dr. Michael Berk and colleagues, in a randomized, double-blind, placebo-controlled trial, evaluated the mood symptoms of individuals with bipolar disorder, half of whom received placebo and half of whom received NAC, as an add-on therapy to their usual treatment.

Over the 24 weeks of the study, NAC was well tolerated, and induced a marked and significant improvement in depressive symptoms. Ashley Bush, M.D., Ph.D., the article’s corresponding author, further explains: “Glutathione is the brain’s primary antioxidant defense, and there is evidence of increased oxidative stress in bipolar disorder. Therefore, we studied the potential benefit of NAC treatment in bipolar disorder and found that it impressively remedied residual depressive symptoms.”

John H. Krystal, M.D., Editor of Biological Psychiatry and affiliated with both Yale University School of Medicine and the VA Connecticut Healthcare System, comments: “The preliminary evidence of efficacy of NAC is very interesting.

This study might suggest a number of novel approaches to treating depression. In subsequent efforts to replicate this preliminary finding, it will be important to determine how much NAC reaches the brain after oral administration.”

As noted by both the authors and Dr. Krystal, additional studies will be necessary to further evaluate and replicate these findings. However, as Dr. Berk observes, “Brain glutathione metabolism appears to be a valuable new treatment target for psychiatric disorders, and we hope the impressive results of this study opens up a new treatment option.”

Article Source: Citation: Elsevier (2008, September 7). Add-On Therapy Improves Depressive Symptoms In Bipolar Disorder. ScienceDaily. Retrieved May 16.

Michael M. Messer, MD
Physician of Behavioral Health, SMDC Medical Center, Duluth, Minnesota

Irina V. Haller, PhD, MS

Introduction
A growing body of evidence indicates that N-methyl-d-aspartate (NMDA) receptor antagonists significantly and rapidly improve depressive symptoms in MDD patients. Two randomized controlled trials, one including treatment-refractory depression (TRD) patients, reported a rapid antidepressant response from a single infusion of ketamine in patients with MDD.1,2 There are no available data or general guidelines, however, on optimal dose, frequency, or inter-dose interval for ketamine administration to sustain remission. This case delineates a dosing regimen and may provide guidance to achieving sustained remission in TRD patients.

Case Report
In January 2008, a 46-year old female with MDD was hospitalized for a course of ECT. Successive interventions over 15 years had included trials of 24 psychotropic medications and 273 ECT treatments, 251 of which were bilateral. No intervention had produced remission but only a short-lived response to treatment. She had no history of an Axis II diagnosis, chemical dependency, or other major medical illnesses.

ECT during this admission was administered with ketamine as the anesthetic at 2 mg/kg given over 60 seconds. Surgical anesthesia occurred ~30 seconds after the end of intravenous injection and lasted ~10 minutes. There was no significant change in depression symptoms with the ketamine used as an anesthetic during the ECT treatment.

Based on recent reports1,2 of rapid antidepressant effect of single dose ketamine in MDD patients, we reviewed the information available with the patient and obtained her consent. We discussed potential side effects known to be associated with the anesthetic dose of ketamine, such as psychosis during or after the treatment, elevations in liver enzymes, hypertension, a harlequin-like skin change, and malignant hyperthermia. At lower doses used for antidepressant treatment2 reported in the literature, side effects included perceptual disturbances, confusion, elevations in blood pressure, euphoria, dizziness, and increased libido, as well as gastrointestinal distress, increased thirst, headache, metallic taste, and constipation. These side effects appeared to abate within 80 minutes after the infusion.

Ketamine was administered at 0.5 mg/kg of ideal body weight (IBW) over 40 minutes. The first ketamine treatment led to a dramatic remission of depressive symptoms: the Beck Depression Inventory (BDI) score decreased from 22 to 6. Three additional infusions administered every other day over 5 days produced remission lasting 17 days after the last infusion in this series. Three series of six ketamine infusions given every other day except weekends were repeated over the next 16 weeks whenever the patient relapsed into depression. Each infusion sequence produced remissions lasting 16, 28, and 16 days, respectively, followed by a relapse. After three remission/relapse cycles and before relapse could occur after the fourth infusion series, a maintenance ketamine regimen was established on August 27, 2008 using 0.5 mg/kg IBW at a 3-week inter-dose interval. We based our estimation for the maintenance dosing interval on the time frame between remission and relapse for this patient. Relapse to depression was prevented by treating prior to the onset of a relapse.

With maintenance infusions, the patient has been in remission for >15 months. No concurrent pharmacotherapeutic agents have been administered or required during this time period, no adverse events have emerged, and there has been no cognitive impairment as is typical with ECT, polypharmacy, or from MDD itself.

Generally, weight-based dosing (eg, mg/kg) is a sound pharmacologic strategy. However, data and experience with weight-based dosing in a previous patient who was substantially overweight resulted in perceptual distortion,3 though antidepressant benefit was evident. In consultation with our Anesthesia department, they selected IBW to establish the dosing regimen. The Metropolitan Life Insurance weight tables4 can be used to determine IBW based on sex, age, height, and body frame.

For this case, ketamine infusions were administered with nursing supervision as a day patient procedure and treatment was well tolerated. Vital signs were monitored during the infusion. No psychotic or dissociative symptoms were noted during or after the ketamine infusions and no other adverse events occurred. Ketamine was safe in an outpatient setting without cognitive or physical impairment once ketamine was metabolized (usually within 2 hours post infusion). Repeated administration did not produce tachyphylaxis or tolerance.

Conclusion
A growing body of evidence suggests that the glutamatergic system, known to play a role in neuronal plasticity and cellular resilience, is also involved in the pathophysiology and treatment of MDD. Ketamine, an NMDA receptor antagonist with rapid antidepressant effect, emerged as a potential agent for treatment of mood disorders.

Optimal ketamine regimens to sustain remission from depression have not been defined. Previously, the authors successfully treated two patients with TRD using a series of ketamine infusions over a 12-day period.3 The patient who received two ketamine treatments separated by 6 days was symptom-free for 18 days and the patient who received six ketamine treatments (every other day over 12-day period) was symptom-free for 29 days.3 As reported by others, remission was followed by relapse.

In the case described here, a maintenance ketamine treatment continues to sustain this patient’s recovery from depression and was more effective in preventing relapse of depression than repeated series of infusions. It may also have some economic and quality of life advantages compared to ECT. As NMDA receptor antagonist action on TRD is explored, a maintenance treatment protocol requires further investigation as a means to sustain recovery from depression.

References

1. Berman RM, Cappiello A, Anand A, et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry. 2000;47(4):351-354.

2. Zarate CA Jr, Singh JB, Carlson PJ, et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006;63(8):856-864.

3. Messer MM, Haller IV, Larson P, Pattison-Crisostomo J, Gessert CE. The use of a series of ketamine infusions in two patients with treatment resistant depression. J Neuropsychiatry Clin Neurosci. In press.

4. Metropolitan Life Insurance Company. Weight Charts. Available at: www.coping.org/weightmgt/strategies/Weight%20Charts.doc. Accessed February 23, 2010.

Disclosure: The authors report no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

Not so with bipolar disorder (BP). First, there are a variety of drugs used to treat BP none of which were created with BP in mind, and second, there is no way that a bipolar person can measure the changes in their brain chemistry and neurotransmitter function, or tell if they need more of less of whatever drug they are currently taking. The only clues that let you know if you need a med increase, decrease, or change is either unwanted side effects from the drug, or a fairly significant and unwanted change in mood.

By the time you get to either of those places, it usually means having to suffer through another trial of medication changes and weathering the side effects, and putting up with the mood swings while waiting to see if the med change works or make things worse. I know that the alternative is not acceptable – having uncontrolled mood swings to the point that life becomes so disrupted and unbearable that it no longer seems worth living, but it sure would be nice if someone out there would come up with a medication or set of medications that are targeted primarily at BP and that are research based. And it would be even better if there was a tool that people with BP could use to measure whatever it turns out that we need to measure to be able to reliably monitor biochemical changes so that we can regulate our medication based on some measures other than subjective explanations to the physicians about “how we feel” and how we are functioning or not functioning well. It doesn’t seem like to much to ask. Of course, a cure would be even better.

Until such a time, it appears that the medication merry-go-round will continue.

Answer: Many people with BP work with a psychiatrist (pdoc) and a therapist (tdoc) to help them learn to monitor and manage how they react to people and situations in life. Sleeping well, taking your medication(s) as prescribed, maintaining a healthy lifestyle, and minimizing stress are essential to gaining and maintaining stability.

Getting regular exercise and eating a healthy diet are extremely important. Getting the appropriate amount of sleep and keeping a regular sleeping schedule helps minimize episodes. Learning methods for coping with stress when it starts to become overwhelming is also extremely important.

Leveraged from my favorite BP Forum. 

Everybody gets sad. You just have to get over it.

Maybe you should take vitamins.

“Behavioral Health” — why don’t you just behave?

You don’t act bipolar at all. Manic depressive maybe, but not bipolar.

You’re just a woman.

You just gotta be stronger.

You don’t look sick!

BP is a scam made up so the pharmaceutical companies can sell drugs.

My dad’s favorite “are u taking ur vitamins”??? what the hell is that…ummm the question should be are you still taking your seroquel.

I made the huge mistake of telling some people at work…Now they are afraid of me ….omg she has BI POLAR!!!!
Like my head is gonna spin around….hello people I have always had this, I didn’t catch it yesterday from sitting on the toilet …..

Attention seeker!

We don’t do crazy here.

Grow up.

“Bi what?” I thought you got through that in your twenties – your heterosexual now!!!

What do you have to be down about, there are children in Africa starving.

If we all went to see a psychiatrist after doing something bad, we’d all be diagnosed with some mental illness or another.

If she was really mentallly ill she wouldn’t have been able to go to work or make any sense.

It’s all in your head. You’ll feel a LOT better if you just get out and do something.

You don’t have a disease, you’re not sick, so you can just get past this. Just think happy thoughts.

Oh, you’re on your period? Well that explains it, besides, females are so emotional as it is. Are you sure it’s bipolar disorder?

I think one of the worst things I have heard is silence….I’ve had people drop out of my life after learning of the bipolar or after getting sick, I guess, of watching me struggle with it.

There’s no physical test for mental illness – therefore it doesn’t exist! All you people are just sad, pathetic patsies for evil psychiatrists and the pharmaceutical industry!

One forum participant responded: Personally, I am both lazy and immoral. Those two traits have little to do with my  bipolar disorder.

My personal ‘fave’ are those comments that are meant to be compliments, but somehow wind up being insulting. For example, “But you seem so happy and together. . .how can you be mentally ill?” This kind of comment makes me want to scream back “Do you realize how hard it is to put on that happy and together act??” What’s supposed to be a compliment turns into my rage at the fact that people don’t realize how hard it is to be healthy!

IPSRT was developed by Ellen Frank Ph.D. from the University of Pittsburgh. IPSRT is based on the observation that disruptions of circadian rhythms and sleep deprivation can stimulate or aggravate bipolar disorder symptoms. It combines behavioral psychology techniques like self-monitoring and self-management, with interpersonal principles, to help people with bipolar disorder maintain systematic routines for sleeping, eating, and other daily activities. 

It is important to stabilize circadian and social rhythms because they are often out of sync in people with bipolar disorder. Therapists who practice IPSRT will work with their clients to help them observe and then regulate sleep-wake cycles, daily routines, and social relationships. Limiting disruptions to these social and bodily “rhythms” can help minimize bipolar episodes in many people.

In an initial therapy session, the client may discuss the times she goes to sleep and wakes, time of day she has meals, what times she typically has her interactions with other people, and whether those interactions are positive, negative, stress producing, stimulating, boring, or emotionally upsetting. I keep a daily journal. I record moods, food, important interactions, exercise, etc. I didn’t realize that I was doing IPSRT.

Monitoring social rhythms can help you identify the  habits and patterns that may be aggravating the disorder. Sleep disruptions are often one of the primary triggers for manic episodes. Highly stimulating events or stressful social interactions during the day can also worsen both mania and depression. I found that I spontaneously eliminated certain people and activities from my life as I began to recover from my 2009 manic episode. Eliminating those stimuli allowed my body and mind to start calming down so that I could return to my pre-manic state. I observed that if a triggering stimuli appeared, I could actually feel the manic energy well up in me, and then I’d have difficulty sleeping for several nights afterwards. Eliminating the stimuli that is contributing to or triggering an episode is essential for recovery.

Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy. Ellen Frank. New York: Guilford Press (www.guilford.com). 2005.

Question 1:

Have you had episodes of clinical depression – involving a period of at least 2 weeks where you were significantly depressed and unable to work or only able to work with difficulty – and had at least 4 of the following:

• Loss of interest and pleasure in most things
• Appetite or weight change
• Sleep disturbance
• Physical slowing or agitation
• Fatigue or low energy
• Feeling hopeless and helpless
• Poor concentration
• Suicidal thoughts

If yes, proceed.

Question 2:

Do you have times when your mood ‘cycles’, that is, do you experience ‘ups’ as well as depressive episodes?

If yes, proceed.

Question 3:

During the ‘ups’ do you feel more ‘wired’ and ‘hyper’ than you would experience during times of normal happiness?

If yes, proceed.

Please complete the checklist below, rating the extent to which each item applies to you during such ‘up’ times.

Quietly and calmly, I picked up a Web MD magazine that was sitting on the coffee table in the cramped outer waiting room and started reading an article on how to minimize stress in your life. I couldn’t help but think that getting up and leaving that office would reduce my stress significantly, but just in the nick of time, my carefree, relaxed, happy, and oh-so eccentric doc yelled out from his office door “Hey, Luann, come on in.” I hightailed it into his office.

We talked about his trip to a Biological Psychiatry Conference and what he learned there. I don’t recall all the details, but he talked about using Ketamine for pain, and new data indicating that it can also be effective for relieving panic attacks. I have a bottle of it sitting in my medicine cabinet but I’ve never used it. My Ketamine is for me to use if my lower back or hip ever goes out again and if I find that I can’t move due to extreme pain. That only happened once and I didn’t have the Ketamine prescription back then. Now, if by chance I ever have a panic attack, I can take it for that too! The wonders of modern pharmacology.

I also learned about the properties of Xanax and how the chemical compound is similar to alcohol but different. Molecules in alcohol and Xanax both bind to GABA receptors but the molecule that makes alcohol addictive is not one of the end products of Xanax. The prevalent view is that Xanax is extremely addictive so very few doctors will prescribe it. My doc is adamant that Xanax is not addictive. I do hope that he prescribes some for his stressed out office colleagues. He also said that alcoholism is a disease of old people. I hope he wasn’t thinking that I’m either old or an alcoholic. Oh sorry. I jumped topics pretty abruptly on you. We jump from topic to topic in our sessions too and that suits my mind. Hope you don’t find it too jarring.

Now, let’s see..what have I left out? Oh yes, my doc also talked a bit about Omega 3 Fish Oil. I use it to lower triglycerides and he said that promising data indicate that large intravenous doses of fish oil are effective in reducing or stopping psychosis. Can you imagine the fish oil burbs you’d have to deal with? If I ever become psychotic just give me some Zyprexa or Seroquel. Skip the fish oil.

My shrink also provided me with some very comforting information. Based on research studies and patterns of manic episodes, especially euphoric mania, on average a major euphoric manic episode will occur only once every 2-3 years. Mind you, that’s on average, and it varies across people. He said that there is relatively little chance that I’m going to have another major episode in the near future, and there’s no need for me to spend time worrying that I might run off with my tai chi instructor again any time soon. He also reminded me that no one died during my manic episode, and that all is well and right with the world at the moment. Umm.. I think the world is pretty screwed up actually, but he says not. Now, that’s comforting to know.

On the drive home, I started thinking about euphoric mania recurring every 2-3 years and I had a brilliant idea. I was eager to share it with my husband. I began by telling him what my doc said about the average rate of recurrence of euphoric manic episodes. I followed up with my brilliant idea suggesting that perhaps we should buy a condo, rent it out for 2-3 years at a time, then when I have a euphoric manic episode, I’d have a place to go. When the mania subsides and I come back home, we could rent out the condo again for another 2-3 years. That way I wouldn’t end up spending so much money on housing next time. We’d monetize the mania and make a profit. He said something like ”Ahh I see, you mean we’d be Mania Moguls”.

Not surprisingly perhaps, my husband wasn’t completely convinced that my idea was totally brilliant. He looked at me a bit strangely and asked me if I’d taken my Lithium, and then he smiled and said that he’d give the condo idea some not-too-serious thought. Luckily, my husband and my shrink both have a great sense of humor!

The author of this article, Benedict Carey, highlights some of the changes that we can expect to see in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) when it comes out in 2013.  Carey says, “…the guidebook  largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.”

Another reader commented, “Definitions of mental disorders will always be controversial. Human behavior and the functioning of the brain are simply too complex to put in boxes with neat labels.” Dr. William T. Carpenter, a psychiatrist is quoted in the article, “….keep in mind that these are individuals seeking help, who have distress, and the question is, What’s wrong with them?”

Perhaps the biggest proposed change to the DSM-5 would be to add a childhood disorder called temper dysregulation disorder with dysphoria. This disorder would provide an alternative to bipolar disorder, hopefully cutting back significantly on the number of children who are misdiagnosed with bipolar disorder.

Anonymous says: “My doctor asked me what my mania feels like when it is coming on. Here are some examples of how I feel:

• I feel something primal – like the call of the wild – like a domesticated dog hearing a pack of wolves calling to him from out in the wilderness. He knows he’s a domesticated dog, but he also knows his heritage, and wants to howl back and run after his ancestral tribe, to become what he was destined to be – a wild animal – a wolf.
• I feel that if the surges become any stronger, I will spin right up and through the roof.
• I sometimes have the urge to climb walls and hang from the rafters.”

Also, you have to remember that each person’s experience is different and what manifests as mania for one person may be totally different for someone else. I love the primal call of the wild example. It resonates with me and makes me recall one summer night years back when I was sitting on the grass in my backyard with friends howling at the moon. That wasn’t mania though, just a little bit too much alcohol consumption, and as I recall, it was a full moon, and I wasn’t the only one howling. Really.

Seroquel brings in almost 10% of AstraZeneca’s revenues. The marketing team being sued over the drug’s alleged side effects tried to suppress key data, an ex-employee has claimed. Seroquel’s former UK medical adviser told the BBC he was pressured to approve promotional material which said weight gain was not an issue.

Thousands of patients are suing AstraZeneca in US courts, claiming the anti-psychotic drug Seroquel caused weight gain and diabetes. The patients allege Seroquel, its second biggest selling drug worth $4.5bn a year, was marketed without adequate warning about possible side effects such as massive weight gain and the development of diabetes. However, this is denied by the company.

Dr John Blenkinsopp, the company’s former UK medical manager, claimed he was pressurised by the company’s marketing arm to approve claims about the drug which he felt did not reflect the medical evidence.

“The clinical studies at the time of the launch of Seroquel showed patients developed significant weight gain, significant both statistically and clinically,” he told the BBC’s File on 4. “They [the marketing team] came at me with a number of potential claims all of which were trying to intimate that Seroquel was not associated with weight gain – the data pointed in the opposite direction,” added Dr Blenkinsopp who was speaking publicly for the first time since he left the company in 2000.

To read the entire article click on: AstraZeneca ‘suppressed’ drug test data

My first response is that 2010 has been fine so far. What on earth does that mean though, and who will ever read this blog if I use words like fine. Fine is a word writers should avoid like the plague. And 2010 hasn’t been exactly fine so far. It’s been kind of blurry and gray. Opps! That’s two words. Try again.

Ok 2010 has been “vigildent”.  It’s often preferable to let readers make their own interpretations, but in the case of the word “vigildent” that just isn’t fair. So, I’ll try to explain.

I’m vigilantly diligent about watching my behavior and moods, trying to ensure that they both stay within the bounds of “near normal”. I also feel kind of vigildent about inspiration. I’m waiting for inspiration and energy to tap me on the shoulder or kick me in the butt. It rarely taps or kicks if you just sit there and wait for it. But lately I’m extremely vigilant about waiting and I’m diligent about being lazy. Overall, I’m being vigildent these days.

Why so vigildent? I think I’ve been worried about becoming “too happy” and going off on another manic tangent. Heaven knows I can’t afford to do that again. I’m still paying on the 6 month lease I took out last time I ran away from home. I don’t think I’d ever run away from home again, but I can’t completely trust myself anymore. So, on go the handcuffs. I’m still fun to be around but I’m tamed down. I’m not boring but I’m on guard.

My last major manic episode started in February 2009 and lasted until around the end of October. It varied in intensity over time, but I don’t recall ever being down. Just full of euphoric energy and extremely irritable at times. I also wanted to save all my relatives and the world. Now, I could care less about relatives and the world. Relatively speaking that is.

Maybe I’m really more worried about crashing. That would make more sense. But worrying about any of it to the point that I keep myself miserably normal is foolish and it won’t work anyway - so it’s a total waste of precious energy, energy that could be much better spent worrying about something much more important like what’s for dinner tonight.

I don’t have any answers but this ”too careful” way of being in the world just doesn’t cut it. I’m going to have to give myself permission to be a little bit less vigildent. In summary, 2010 so far has been packed with vigildence. I hope to be able to report next time that it’s been more carefree and capricious. Opps. That’s two words again.

Myth: People with Bipolar Disorder having either a manic or depressive episode can ”think positive and snap out of it” if they really try. False. Bipolar Disorder is a real bodily disease it’s not just all ”in your mind”. This next analogy is great. I found it on the Depression and Bipolar Support Alliance site. Asking someone to ‘ just  think positive” is like asking someone with diabetes to change his or her blood sugar level by just thinking about it. 

Myth: If you are diagnosed with Bipolar Disorder, your chances of having a great career life are nonexistent. False. Many talented and successful people have Bipolar Disorder.

Myth: Bipolar Disorder is characterized by frequent mood swings. That’s usually false. In fact, the opposite is often true (with the exception of some rapid cyclers). According to Dr. Jean M. Bradt, people with bipolar disorder often get stuck in one (high or low) mood for significant periods of time, no matter what is going on in their lives. 

Hear Dr. Jean M. Bradt: “A bipolar woman may become manic and, regardless of anything bad that happens to her, stay manic for weeks, even months. A bipolar man may not be able to pull out of a depression for years.”

“In real life, good and bad things happen much more often than every few months. And the moods of those of us not diagnosed with bipolar disorder tend to correspond fairly well to what is actually happening. The moods of untreated bipolars, on the other hand, correspond more to the chemicals in their brains than to the events in their lives. This gives most bipolars less frequent mood swings than others, on average.”

John McManamy writes a blog about Bipolar Disorder and in one of his articles he talks about some of the myths surrounding the disorder. 

Myth: John writes, “Bipolar disorder is a mood disorder. Half true. Bipolar disorder certainly affects mood, but it also affects cognition and the ability to perform mental tasks. Some days we can out-think Stephen Hawking. Other days we make Forrest Gump look like an intellectual.” I can certainly relate to that!

Dr. Jay Carter also dispels myths in his book, and I particularly like the myth about just using your self-discipline to overcome the illness. 

Myth: “If you exercise enough self-discipline you can prevent yourself from being incapacitated….” Dr. Carter writes, “False. People… may win a particular battle, but they are incapable of winning the war. Furthermore, why should be have to spend all our time fighting?” I agree that just using self-discipline will not get you very far. You will expend a lot of energy and still end up struggling more than necessary.

I hope this article helps you better understand some of the myths and stereotypes surrounding Bipolar Disorder.

During a recent talk regarding my book, “Blessed with Bipolar,” I was stumped by the question, “How does a person get to where you are now from where you were in the psych ward?” I actually have a 380 page answer to that question. What stumped me was the question behind the question: “How do I get my bipolar daughter into treatment?”

It is a great irony of bipolar disorder that while it is perhaps the most treatable of mental illnesses, those of us who have it often wholly reject even the mention of “getting help.” When we’re on a manic high, we don’t see any need for treatment. When we’re crushed with depression, we think we’re too far gone for it to do any good. And when we are in a mood-swung, irascible and erratic temper . . . well . . . “see a counselor” is fightin’ words.

But the question of how to persuade a bipolar loved one to seek treatment deserves a response. Here’s my attempt:

• Don’t try to convince her that she is mentally ill. Anybody in their right mind would rebel against that reasoning. This approach will just get you a long list of reasons why she thinks you are wrong. Nobody wants to think of themselves as mentally ill.

• Acknowledge the hard and courageous struggle she has put up against whatever legitimate adversity there is in her life. She has kept trying to succeed on her own in many ways. And sometimes has. She needs to know that you recognize that.

• Let her know that you believe in her goals and that the emotional pain in her life seems to be an obstacle in the way of achieving those goals.

• Suggest treatment as a way to achieve goals rather than a cure for mental illness.

• Look at the situation as a “family issue” and offer to go into treatment with her. This may be difficult for you because I am not suggesting that you attend counseling sessions as a ‘co-therapist’ for your loved one. Let the counselor do the counseling. I’m suggesting that you seek treatment with her to address the difficulties in your relationship with her. That requires you to own responsibility for part of the problem, to see the role you play in it, and to work at making effective changes in your own thinking and behavior. That may sound like a challenge to you. And it is. But it’s no different than the challenge you are making to your bipolar loved one. What’s it worth to you?

Convincing a loved one to seek treatment for bipolar disorder is no easy task. I had enough good times to believe that I was mostly healthy and too much pride to seek help when I was not. The steps above may not work, but they are worth a try. At the very least, it is a good way to approach the treatment issue without the usual “I’m not crazy!” screaming match.

Richard Jarzynka is the author of “Blessed with Bipolar.” He has used the disorder to help him counsel clients; run a marathon; grow in his faith; and earn a masters degree in psychology, a scholarship to Law School, and a football scholarship.

Source: http://www.articlealley.com/article_1299120_17.html

Could You Be Bipolar?

You are at the highest risk.

Your moodiness appears to be affecting how you function, your financial security and/or relationships. Talk to your doctor about your own medical and family history and consider getting a physical exam and a more thorough screening test.

Annoyingly smart little test engine. I believe that the quiz included only 5 or 6 questions. Here’s a link to the Could You Be Bipolar test.

One of the standard psychological tests that I’ve found in several locations on the internet is the Goldberg Screening for Bipolar Spectrum Disorders. It’s has quite a few questions and takes more time to complete. I don’t have time to take it now because dinner’s ready, but I’m sure that I’ll do exceptionally well on it too!! Lucky me.

I found a well written and very clear list of symptoms of bipolar disorder to share with you. To read about these symptoms go to manic and depressive symptoms . The site is simple and easy to navigate.

Today - 1/12/2010,  Etiquette Rule #1.    

1. Never, never, ever tell a person in either a manic or depressed episode to “just snap out of it”. This phrase has been used by well intentioned non-bipolar individuals in an attempt to help their friend or loved one perk up or settle down mood-wise. In a poll conducted on a bipolar forum site, an overwhelming number of bipolar individuals found this phrase offensive, inappropriate, and extremely annoying. I assure you that the bipolar person would snap out of it if there was any way to do so. People who don’t have bipolar disorder(BP) have to remember that the ups and downs of BP are not just simple mood swings that we can control easily.

Other things you definitely want to avoid saying to a person who is having a manic or depressive episode:

• Quit being so moody
• There are a lot of people in the world who are a lot worse off than you
• And you think you’ve got problems….
• Why can’t you just act normal?
• It’s all in your mind (We’ll duh)
• Pull yourself up by your bootstraps
• You have such a great life - why aren’t you happy?
• Lighten up (a variation of just snap out of it)
• You really need to quit taking those pills
• You need to get out more
• Just do yoga
• Just stop eating processed foods. You must be eating too much sugar and refined flour

Instead you might say one or more of the following:

• I’m sorry you’re suffering right now
• You’re important to me
• You’re not alone in this
• If you need a friend, I’ll always be there for you
• You have so many amazing gifts – how can you expect to live an ordinary life?
• I can’t imagine what it’s like for you. I can only see how hard it must be
• I’m never going to say, I know how you feel unless I really do, but if I can do anything to help you, I want you to know that I will

Protein kinase C has been implicated in bipolar disorder. Current thinking is that there is an increase in protein kinase C signaling in the brains of people with bipolar disorder. This increase is associated with prefrontal lobe grey matter as well as with impulse and behavioral control.

In this study, researchers blocked the action of these enzymes in rats, and they found that their ability to focus on and complete tasks using working memory improved as did their impulse control. Arnsten said: “When you inhibit protein kinase C, cells can talk to each other again and you rescue cognition.”

We know that lithium therapy inhibits protein kinase C and lithium also generates new neuronal networks in the brain.  To read more go to: Yale Researchers Repair Brain Damage Caused By Chronic Stress Work Has Implications For Bipolar Disorder, PTSD

Researchers from Cardiff University collaborated with over 200 scientists and analyzed the DNA of 17,000 people to identify and better understand how genes impact bipolar disorder. This was a UK wide collaborative effort.

The Cardiff investigators found that there are many genes that can put an individual at a greater risk of getting bipolar disorder. They also found that an individual gene on its own makes only a small contribution to that risk. The researchers also indicated that the results of the study provide important insights into the biological systems behind bipolar disorder, a disorder that impacts over 100 million people. Several of the genes that were identified during the study, were found to play a key role in the way nerve cells in the brain interact with each other.

Hear Professor Craddock:  “This is the largest and most powerful genetic association study of bipolar disorder undertaken to date. The powerful molecular genetic approaches that we are using provide a window into the workings of the brain in those suffering from bipolar illness….This should be a time of great optimism for those individuals and families that have experienced illnesses like bipolar disorder…..”

Source: Cardiff University – News Centre

Rumor has it that there is a new personality disorder (PD) plaguing  a large number of people all over the world. This new disorder has finally been documented by non other than Shake, a participant on one of the more popular bipolar forums.

I asked Shake if I could leverage his PD description and he said:

“Yes, feel free to publish it in any way you like, as an oft-struggling writer, I’ll take any kind of publishing I can get.”

Well, here it is. And thanks Shake.

Square As A Box Personality Disorder, or “Pathological Normalcy”

“Here’s a little something I perfected last night… I call it Square As A Box Personality Disorder, or “Pathological Normalcy” if you will.

So, with tongue firmly in cheek, here it is -

1. Lack of imagination; difficulty seeing things that are not immediately perceptible, little to no understanding of artistic license, “earth bounded- ness”

2. Distrust of intuition; over-reliance on linear thinking, over-cautious in drawing conclusions, impaired ability to perceive nuances, innuendo.

3. Conformism; bound by convention, excessive fixation on ritual and routine, hostility towards unconventional persons, ideas, beliefs; Willingness to suppress authentic self in order to win social approval.

4. Creative deficits: almost non-existent creative ability, lack of confidence in creative process, envy and resentment of more creative individuals.

5. Hyper-extroversion; unwarranted and irrational fear of being alone/left out; superficial social relationships; avoidance of reflection, contemplation.

6. Excessive sensation-seeking; inability to entertain oneself from inner resources, numb sensibilities, need to unnecessarily expose oneself to danger, sometimes illicit/illegal activities are pursued for amusement.”

I think Shake may be on to something here. Do you know people who fit the criteria for this new disorder?

A study comparing monotherapy with lithium and combination therapy with lithium plus valproate found that both were more likely to prevent manic relapse than was using valproate by itself. The benefits of using either lithium alone or lithium and vaproate appears to be irrespective of the baseline severity of the disorder, and ability to avoid relapse episodes may be maintained for up to 2 years.

These are the conclusions of the BALANCE study, published Online First (www.thelancet.com) and in a Lancet article, written by Professor John R Geddes, et al. Dr. Geddes is with the Clinical Trials Unit for Mental Illness, University of Oxford, UK.  The BALANCE study results did not indicate that using combined therapy instead of lithium by itself was more desirable. There was no statistically significant difference between outcomes of patients taking lithium only versus patients taking lithium plus valproate.

In the randomized BALANCE trial, 330 patients ages 16 years and older with Bipolar I Disorder from 41 sites in the UK, France, USA, and Italy were assigned to lithium treatment alone, valproate treatment alone, or both lithium and valproate together. The study followed the patients for 24 months.

Researchers found that 54% of people in the combination therapy group, 59% in the lithium group, and 69% in valproate group had a mood episode during the 24 month follow-up. In terms of relative risk, those given combination therapy were 41% less likely to have an episode versus those given valproate; while those given lithium were 29% less likely to have an episode than those given valproate. Both findings were statistically significant. Patients given combination therapy were also 18% less likely to have an episode versus those given lithium monotherapy, however; this finding was not statistically significant.

The investigators state that: “The results of BALANCE show that for people with bipolar I disorder for whom long-term therapy is clinically indicated, combination therapy with lithium plus valproate is more likely to prevent relapse than is monotherapy with valproate. The 41% relative benefit is irrespective of baseline severity of illness, is maintained for up to 2 years, and is most apparent in prevention of manic relapse.”

They further conclude that: “The main BALANCE findings have important implications for clinical decisions about long-term therapy for bipolar disorder. First, valproate monotherapy is recommended by clinical practice guidelines as a first-line option for long-term therapy. Our results suggest that patients should be advised that a better outcome would be likely with combination therapy with lithium plus valproate semisodium or lithium alone. Second, guidelines suggest that patients who have frequent relapses during treatment with lithium monotherapy could switch to valproate monotherapy. The results of BALANCE suggest that these patients would fare better if they changed to combination therapy.”

Dr Rasmus W Licht, Mood Disorders Research Unit, Aarhus University Hospital, Denmark, says that the results of BALANCE, even without a placebo group, confirm the long-term efficacy of lithium, not only for the prevention of mania but also for prevention of depression. Hear Dr.Licht: “On the basis of their overall results, the BALANCE group rightly challenges the recommendation by present clinical guidelines that valproate monotherapy is a first-line option for long-term treatment.”

He concludes: “By a diligent balance of external and internal validity, BALANCE surely reflects its acronym. It is remarkable indeed that a clear signal could be detected despite the straightforward study procedures, including the allowance of co-medication, and there is no doubt that the trial sets the stage for future large-scale, simple, investigator-sponsored trials.”

So today, there’s this underlying anxiety trying to bubble up and a tendency to start crying for no reason.It’s hard to describe unless you’ve experienced it, but imagine yourself driving along and all of a sudden you feel very sad, and you start crying. But you’re baffled because two minutes ago you were happy as a clam at high tide. Apparently clams love high tides.

Then the feeling and crying stop and you think – whew – that’s over.  But a couple of hours later it happens again and lasts a little bit longer.

What’s frustrating is that I think I’ve been doing all the right things. I’ve been eating properly, exercising, keeping stress to a minimum, and taking my meds. I’m hoping that maybe I just didn’t sleep well last night and that tomorrow will bring me back to my more balanced self. We’ll see.

Millions of people with Bipolar Disorder (BP) take medications to help them manage their symptoms so that they can live rich, creative, and productive lives.

Currently, there are many medication options for BP.  Lithium has been used for years and has proven to be quite effective for many people. Lithium combined with Depakote ER works well for me, however, not every medication works for everyone and finding the right medication or combination of medications can be challenging. It is interesting to note that since the discovery of Lithium’s effects on reducing mania more than 50 years ago, all other medications currently used for BP were not specifically developed to treat BP.

For example, the group of drugs called anticonvulsants were initially used to treat epilepsy. Now, they are also used as mood stabilizers for people with BP. Some of these drugs include:

• Depakote, Depakene ( valproic acid, or valproate sodium): Normalizes brain cell rhythms and increases the amount of GABA in the brain.
• Lamictal ( lamotrigine): Blocks glutamate, a neurotransmitter in the brain.
• Tegretol (carbamazepine): Stabilizes brain cells. Some people feel that it causes less weight gain than either Lithium or Valproate.
• Trileptal ( oxcarbazepine): Tegretol is not studied as much as Depakote and Lithium. Most studies show Tegretol to be as effective as Depakote and Lithium.

I tried Lamictal several years ago, and had to stop taking it. It made me very angry and irritable. But, it worked wonders for one of my friends. She tried Lithium years ago and did not do well on it. So, again you need to work with your doctor to find out what works best for you.

Atypical drugs: This label refers to a group of drugs called atypical antipsychotics. Don’t worry, it doesn’t mean that you are psychotic if you take one of these drugs anymore than it means that you are epileptic if you take an anticonvulsant drug. What it means is that these drugs like anticonvulsants were used for a different purpose years ago, and now they have been found to be effective in treating BP. There are regular antipsychotics and the newer class of drugs called atypicals. I’m sharing information with you in this article about atypicals. Most atypicals are now licensed by the FDA as treatments for BP. Some doctors prefer to call this class of drugs neuroleptics.

• Seroquel (Quietapine): I’ve found it to be very sedating. Quiets racing thoughts, tones down mania and depression. Works well for me in conjunction with Lithium.
• Zyprexa (Olanzapine): Worked well for me but I gained 12 pounds in 3 months several years ago.
• Geodon (Ziprasidone): Similar to the others but it is supposed to be weight neutral, meaning that you won’t gain weight when taking it.
• Clozapine (Clozaril): This was the first atypical. It can cause blood problems and according to the literature is very sedating and can cause significant weight gain.
• Risperidone (Risperdal): My experience with Risperdal was not good. I took it at night and it really wound me up. I was wide awake all night long. I think they call that a paradoxical reaction. I reacted the opposite of the intended effect of the drug.
• Abilify (Apipiprazole): Seems popular right now in the media anyway. I’m not familiar with it.

Antianxiety Medications: Medications used to relieve BP anxiety are called benzodiazepines. They include:

• Xanax (Alprazolam): Good tranquilizer and very fast acting. Short half-life so it wears off more quickly than Klonopin.
• Ativan (Lorazepam): Sedating.
• Klonopin (Clonazepam): Acts more slowly and for a longer time than Xanax. Some physicians prefer to prescribe this rather than Xanax because they believe it to be less addicting.

These medications are sedatives and can be very effective in lessening anxiety, however, they don’t treat the core problems of BP like mood stabilizers do. Doctors often use benzodiazepines sparingly and they stay away from Xanax because it it considered the most addictive benzo.

It’s common for people to work with their physicians to find a combination of medications that work together to treat BP. I’m currently taking Lithium Carbonate and Seroquel and the combination is working for me right now. But that doesn’t mean that I’m cured or that it will work well forever, no, the tricky thing about BP is that you will find yourself making occasional and sometimes frequent changes to your medication regimen. You have to remember that just taking medication doesn’t cure BP, it only helps manage your symptoms.

To learn more about these medications, simply type the drug name into your search engine and you will find quite a bit of information about each drug.  You can also find sites where patients rate the drugs and share both their positive and negative experiences using them. Really, the bottom line here is that you will need to be patient with yourself as you explore ways to manage your BP. Medications may prove to be one of the tools that you use to help you do that. I’ll explore other BP management tools in future articles.

Disclaimer:  The content in this article is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

I am surprised at how long it takes for clear-headed thinking to return. The racing thoughts are finally receding. I’m able to be in the present and enjoy people and things around me without that awful pressured feeling. I don’t know how to describe that pressure – it’s almost like you have to keep moving, going, doing, running, racing. It’s exhausting.

Reminders:

• Mania can manifest as euphoria, anger, or anxiety, or all three combined together.
• During manic episodes, you will often not be able to see the havoc you are wreaking, and how you are hurting yourself, your family, and friends. So, you are often reluctant to stop doing what you are doing because you are convinced that it is the “right” thing to be doing.
• I’ve found that it takes weeks even months for the brain to start functioning correctly again, so that you can review what you’ve been through and realize the effects of your actions.
• Early mania feels wonderful, at least to me, and it is very seductive and easy to run with it. Unfortunately, it usually leads to impulsive decisions and actions that end up in disaster.

Try not to take it personally if your friend or loved one with BP is occasionally incapable of relating to you in their typical way. When a person is having a manic episode, for that time period, they are often incapable of refraining from behaviors that seem out of character. The prefrontal lobes in the brain are not working properly and the person having a manic episode will often say things that they would not ordinarily say, things that might hurt your feelings, or that you might find offensive. When the lobes are not working, there is a decrease in inhibitions. Jay Carter Psy.D. writes about the importance of family and friends not taking a manic person’s words and actions personally.

As Dr. Carter says, “It doesn’t mean that you disassociate or disregard what the person says….You simply know that a person who thinks “it’s all about me” does not function as well as someone who knows it isn’t.” In other words, you need to remember that It’s Not About You. It’s about the person with BP.

To learn more about how you can help yourself and your friend or loved one with BP, read books, magazines, and blogs about BP. Doing so will help you better understand what your friend or loved one is experiencing. Participate in therapy sessions or support group meetings if appropriate. And remember: Don’t Take It Personally!

I recommend reading The Complete Idiot’s Guide to Bipolar Disorder by Jay Carter, Psy.D., and Bobbi Dempsey.

In her writing she describes herself as an “exuberant” person, yet longing for peace and tranquility; but in the end, she concluded that she prefers “tumultuousness coupled to iron discipline” over leading a “stunningly boring life.”

Here is an excerpt from her book An Unquiet Mind:

“I long ago abandoned the notion of a life without storms, or a world without dry and killing seasons. Life is too complicated, too constantly changing, to be anything but what it is. And I am, by nature, too mercurial to be anything but deeply wary of the grave unnaturalness involved in any attempt to exert too much control over essentially uncontrollable forces. There will always be propelling, disturbing elements, and they will be there until, as Lowell put it, the watch is taken from the wrist. It is, at the end of the day, the individual moments of restlessness, of bleakness, of strong persuasions and maddened enthusiasms, that inform one’s life, change the nature and direction of one’s work, and give final meaning and color to one’s loves and friendships”.

From the organizers:

“The Bipolar Expedition is an initiative developed within the Australian branch of the successful Brightest Young Minds Foundation, an organisation which provides a platform for young Australian adults to launch ventures to address pressing social issues.

We are passionate about finding better ways to manage and diagnose Bipolar Disorder. An expedition team led by extremely experienced guides, and consisting of people with Bipolar Disorder, psychiatrists and community members, will embark on two separate treks, approximately 3 weeks each – one to the South Pole and one to the North Pole.

This entire journey will be made into a documentary to raise awareness for Bipolar Disorder. Participants need to be aware that this is an integral part of our mission.”

To learn more about the goals of the project go to: http://www.bipolarexpedition.org

Stephen says -

I’ve been married for 19 years to a woman who was diagnosed as BP 8 years ago. To say that we’ve been through a lot is an understatement. Hypersexuality, mania and the resultant infidelity are things that we’ve had to deal with several times.

There are times when people with BP simply cannot exercise good judgment. Any competent care provider will tell you this. People with BP WILL do things that affect their families. That’s just part of being related to them. Although its really impossible to separate the illness driven behaviors from their personality, spouses and other family members need to understand that BPD changes the way people, think, feel and act. Allowances must be made. Not to do so is unfair because it holds people to unrealistic standards and disappointment becomes the inevitable outcome.

It is very hard to know that your spouse has sex with other people, becomes infatuated with other people, and can even turn against the people that love them most.For many people, these are unbearable behaviors. However, the reason they are unbearable is that they conflict so strongly with expectations. So you have two choices: moderate the behaviors and/or moderate the expectations.

It has taken years for us to come to grips with the fact my wife has BP. Fortunately, my wife is really good about taking her meds and seeking therapy. Even so, she has the occasional bout with mania so, for example, we now have an 11 month old girl by another man.

I could get all upset about that, demand a divorce, etc. But the truth is, I love my little girl and I still love my wife.

Joe says in response -

Stephen–

I think you must be more tolerant than the rest of us mere mortals, because I’m not sure I would put up with quite so much. You mention two choices: moderate the behaviors and/or moderate the expectations.

First, “moderate the behaviors” can mean all sorts of things from the person with bipolar willingly taking her medications and putting an honest effort into maintaining mood stability to forced commitment. Too much tolerance, I believe, can lead a loved one to inaction, which can actually be harmful to the person with bipolar, not to mention yourself and everyone else involved.

I would question whether too much tolerance would be beneficial to the person with bipolar. If the person has no limits, faces no consequences for destructive behaviors, she has license to do anything. This is not good for her or her loved ones.

From my experience, a certain amount of tough love is required.

Oh yeah, my second point is that there’s a third option – leave. I’m not advising anyone to take this step lightly, but if the person with bipolar is doing nothing to help herself (or himself), I couldn’t fault anyone for taking this choice.

To read the entire article go to Dr. Candida Fink’s Bipolar Blog Information and Support site.